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For as much as she wanted to get the COVID-19 vaccine as soon as possible, qualifying because of her weight was an uncomfortable proposition for Laura Baisas, a freelance science writer and graduate student living in New York City who got her first dose of the vaccine on March 1.

“I’ve had such complex feelings (about qualifying because of her weight),” Baisas says, because “most people wouldn’t know my BMI was high enough to qualify just by looking at me.” Though her body mass index, or BMI, was just barely over the threshold, it was high enough to tip her into the eligible category.

Many states have used BMI, which is a calculation of height and weight, as a factor considered in the triaged roll-out of vaccines. It’s one way to help determine who should go first with limited supplies available.

So when Baisas, who’s 32 and mostly healthy, found herself eligible early in the deployment, that raised long-standing difficult feelings surrounding weight and body image. An avid swimmer and endurance athlete, Baisas has struggled with body image throughout most of her life.

Initially, she was embarrassed that her weight made her eligible. “I hate that this thing that I’ve hated for so long is what’s going to qualify me for a shot,” she remembers thinking. She also wondered whether it was ethical for her to take it when others are in need too.

But after talking with family and friends, she came around to the idea that maybe it was better to just take the shot being offered rather than get hung up on how she felt about being labeled as “obese.”

“I kept thinking back on the what Dr. (Anthony) Fauci said, about how we just need to get shots in arms right now. So I decided to suck it up and stop being so embarrassed by it,” she says. It was time for her to do her part to help build the herd immunity that will help protect herself as well as others in her community.

Baisas came to the realization that it didn’t matter what was triggering her eligibility. It was her turn. So she got the shot.

And that’s a good thing – despite the emotional conflict that comes bundled up for many people who have BMI or obesity as a qualifying factor for COVID-19 vaccination – because being overweight or having obesity can be very dangerous when it comes to COVID-19.

Why Weight Is a Factor for Vaccine Eligibility

The reason people who are carrying extra weight have been prioritized is simple: They’re more vulnerable. There appears to be a strong connection between a high BMI and severe infection from COVID-19 that’s concerning enough to warrant a BMI of over 30 as being a risk factor for severe outcomes.

That’s according to research conducted by Dr. Sanjay Kurani, medical director of inpatient medicine at Santa Clara Valley Medical Center in San Jose, California, and co-creator of a set of criteria that indicate how sick COVID-19 patients will typically get.

“As the pandemic hit the U.S., we found our ICU was also getting filled with middle-aged males who were obese, perplexing us,” Kurani explains. “We teamed up with our analytics team to try to find answers in the data. We looked for prognostic risk factors associated with COVID-related hospitalizations and found obesity with a BMI of greater than 30 to be one of those risk factors that correlated with higher mortality,” he says.

Based on that work, Kurani and his team developed a prognostic risk score called the ABC-M score. If you’re over age 60, a point is added to the score. Same for a BMI of 30 or greater. If you have diabetes, cardiovascular disease or COPD, each one of those conditions adds another point. So does being male.

“Those with a score less than two were found to have a favorable prognosis versus those with higher scores,” Kurani says. “The score is automatically calculated in the electronic chart and has been used as a tool by our emergency room health care providers to triage and manage patients with COVID.”

Why Does Obesity Heighten Risk in COVID Patients?

Exactly how obesity or a high BMI can contribute to worse outcomes from COVID-19 infection is not fully understood, but Kurani says that “obesity is frequently associated with insulin resistance and diabetes, which compromises immune function.”

Plusobesity and respiratory conditions often go hand in hand, such as obstructive sleep apnea, Kurani notes. COVID-19 ravages the lungs, so a preexisting lung condition such as asthma, which sometimes occurs alongside obesity, makes COVID-19 a far more serious affair. Heart conditions are also connected with obesity in many patients, and that can contribute to worse outcomes from COVID-19.

Underlying all of these chronic conditions is inflammation. Obesity can cause a state of chronic inflammation in the body, which actually alters how the immune system responds to threats, says Dr. Matthew Apel, a bariatric surgeon with Blossom Bariatrics in Las Vegas. “Someone with obesity already has an impaired immune system, because they have chronic inflammation and a propensity toward blood clotting.”

Because of the chronic inflammation, when the immune system is called to fight a virus like the coronavirus, “it’s already been spread too thin,” Apel notes. Because of the excess fat, “you can’t divert the entirety of the immune system toward fighting the infection because it’s already having some low-grade, smoldering inflammation.”

This means that “COVID is certainly among those infections that people with obesity don’t fight as well, and they tend to have a worse outcome when they get sick.”

There are also practical concerns associated with severe COVID-19 infections and obesity. For example, it can be more difficult to intubate people who have “central adiposity, meaning you have a very large, heavy abdomen because of extra weight,” Apel says. The pressure associated with excess weight around the middle can make inserting a ventilator more difficult.

Plus, turning that person onto their stomach, a practice called proning that can help “recruit different parts of the lungs to make ventilating them easier,” is “nearly impossible in someone who’s morbidly obese,” Apel says.

The chances that someone who’s very overweight will need this kind of advanced care is higher because of the “amplified pro-inflammatory response leading to further damage of the lungs and body,” Kurani adds. “The combination of all of these factors associated with obesity can result in a perfect storm leading the body to succumb to COVID.”

Get Vaccinated When It’s Your Turn

Apel says that anyone who has a BMI of 30 or greater “should have some concern” about COVID-19 and seek vaccination. “When you get a BMI of 35 or higher,” then you should definitely seek the vaccine. You can calculate your BMI via the National Heart, Lung and Blood Institute’s website.

The BMI scale has limitations – it’s a mathematics equation that doesn’t take into account body type or volume of muscle mass. Indeed, some athletes, particularly weight lifters or others who tend to bulk up for their sport, may have a high BMI that’s not fully reflective of their overall metabolic health.

“Yes, you have to take the BMI with a grain of salt,” Apel says, noting that an Arnold Schwarzenegger-type might clock in as morbidly obese while actually being a picture of health. “There’s always exceptions to the rule.”

But for the average person, and “the vast majority of the population,” he says, BMI can act as a kind of shorthand that can help you assess your vulnerability. Generally speaking, the higher your BMI, the more likely you are to have complications if you contract COVID-19, and thus, you’re considered high risk. High-risk individuals are encouraged to get vaccinated against COVID-19 as soon as possible.

Removing the Stigma

Regardless of the specific reason why you’re considered high risk, if you’ve been prioritized to get the vaccine, you should, Kurani says. “And that includes those with obesity, which we know is a condition more prevalent in the Black and Latinx community and a significant reason why this population suffered disproportionately greater from COVID.”

But vaccine rollout has been messy in some communities, and it hasn’t been without its hiccups. Finding the balance between delivering shots and reaching vulnerable populations where they are in an equitable way has been challenging.

Adding body shaming to the mix isn’t helpful, because it can make people with obesity feel bad about their eligibility and thus lead them to hesitate accepting the vaccine.

Kurani says reframing the question about obesity might help those with a higher BMI feel less like they’re “jumping the queue” and actually addressing a real medical concern.

“Those who have obesity have a disease. If it’s viewed that way rather than as a personal failure, then it can be properly treated and managed. The first step is to make the decision to treat it as a health condition and not deferring it for later.”

Apel agrees that removing the stigma and getting vaccinated when you can is best. “The downside is tremendously low. And the upside is tremendously high. If we can choose a patient population that’s going to be best served by not getting sick in the first place or having less severe symptoms, it’s going to be the morbidly obese patient population. Because once those patients get COVID, they have poorer outcomes and are harder to treat in the ICU. In terms of allocation of resources overall, there’s not a better patient population to target.”

When it comes to managing obesity, diet and exercise are important. But Kurani recommends working with a supportive health care provider who specializes in this area of medicine. “There are a number of ways health professionals can manage obesity successfully through education, lifestyle modifications, medications and surgery if appropriate. It’s much more complex than ‘just eat less,'” he says.

Shots in Arms

Just a few weeks after Baisas was able to schedule her appointment for the COVID-19 vaccine, her “normal-weight” husband also became eligible when New York State opened vaccination eligibility to all adults over the age of 30. He, too, took the first opportunity open to him to schedule an appointment.

Baisas says being so close to being fully inoculated “feels really good because as somebody who knows how science works, I can’t believe that it was developed this quickly. I had some skepticism that this was going to happen this quickly, but that makes it feel extra sweet in some ways.”

She also notes that it felt historic to be an early adopter of the vaccine, and getting her shots reminded her of images she’s seen of kids in the 1950s getting the polio vaccine with “stickers that said, ‘I’m a polio pioneer.’ It feels like you’re doing a public good.”

It’s this focus on smart personal health choices that can benefit the individual as well as the general public that Kurani hopes will last after the pandemic is over.

“I hope that the silver lining to this terrible pandemic is the prioritization of health in our society,” he says, with hope that the rapid adjustment the health care system made to address this pandemic can be further leveraged in the future to help treat obesity.

“Our society and health care system had to transform rapidly to handle the pandemic. These transformative efforts can be used to address another epidemic that silently kills hundreds of thousands of Americans every year, the obesity epidemic. We should view this period as we come out of the pandemic as an opportunity to improve our health as a nation.”